Field Note

Yet Another Maternal Death: A True Story from Pakistan

By Dr. Abdul Bari
Save the Children/USA

HARIPUR, Pakistan -- As a physician who has worked extensively for U.S.-supported programs in Pakistan, I have seen both the difficulties and successes for improving health. Strong support by the U.S. for these programs has contributed to significant health gains for children and women. I believe they are all the more required now in this time of crisis.

The story below illustrates the typical issues we all deal with when trying to reduce maternal mortality. It is taken from Haripur, a district located in the North-West Frontier Province of Pakistan. In this primarily rural district of 700,000 people, nearly 30,000 births occur each year. It is estimated that 111 mothers die every year due to pregnancy-related complications, and many more suffer from morbidities related to their pregnancy and delivery. The infant mortality rate is 91/1,000 live births (UNICEF: The State of the World's Children, 2000) thus, 2,700 children die before seeing their first birthday.

In the village of Bonga, not very far from the city, a 25-year old woman, named Jamila Khatoon (names have been changed), died seven months ago after giving birth to twin baby girls. She leaves behind a family of four children -- the twin girls, another girl and a boy. Jamila's husband, an army man, was away on duty in a distant station during the time of delivery, and had left Jamila living under the typical joint family system with his parents. According to her mother-in-law, Jamila was fine throughout her pregnancy and there was no evidence of danger signs at any stage during the nine months. At one point during her pregnancy, she went to a female doctor in Haripur, where an ultrasound report showed that she had twins. The doctor recommended that the delivery be conducted in a health facility rather than at home. However, her in-laws were totally against her delivering outside the home because it is a matter of shame to go out in an advanced state of pregnancy.

On the day of delivery, a traditional birth attendant (TBA) was called in at 4 o'clock in the morning. On the suggestion of the TBA, a "doctor" Malik was also called, who gave Jamila two injections. One injection was to improve her physical health and the other one for "easy delivery." Soon after the "doctor" left, both babies were delivered at 9 a.m. However, Jamila was seriously sick. She was extremely cold and was not responding to the questions that were being asked by her relatives.

Her mother-in-law ran to her elder son, who was working in the fields, to try to get Jamila to a hospital. She arrived back half an hour later to find that Jamila was dead. Interestingly enough, Jamila's father-in-law had gone to the government hospital at 6 a.m. that day and was waiting there for his daughter-in-law to be brought in. He then sent a vehicle to the village at 9 a.m. The people, who were sent to fetch the patient, wasted a lot of time waiting for Jamila's brother-in-law to come back from the field. By the time he arrived back, Jamila had died.

Jamila's mother-in-law was contacted through a community health worker. She was apprehensive of visitors asking about the events leading to the death of Jamila. Her in-laws do not want to discuss the matter anymore. They were even angry with the community health worker who took SC/US staff there to discuss the matter. Seven months after Jamila's death, her in-laws are reluctant to discuss the past events. Fortunately, the twin girls survived. One lives with her maternal grandparents and the other with her paternal grandmother. What will befall them, no one knows. However, being girls and without a mother, apparently the future for them seems very bleak.

The conservative nature of the society is such that even if there are services available they are not utilized during a complication because the decision-makers (the husband and parents-in-law) do not take the woman to a health facility. Usual restrictions for pregnant women are: there are no female attendants at the health facility; there may not be any male members available to accompany the patient; and, quite simply, a woman cannot leave her home in an advanced state of pregnancy.

Many tragedies of maternal or neonatal death occur here at the household level. The low social status of women is one of the major contributing factors to these occurrences. Normally, these poor women are just forgotten without following-up on the events that lead to the tragedy. Everything is said to be the "Will of God." This provides an excellent garb for all concerned to hide under.

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